VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Peter Paul Development Center
1708 North 22nd Street
Richmond, VA 23223
(804) 780-1195

Current Inspector: Susan Ellington-Sconiers (804) 588-2368

Inspection Date: March 16, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 ADMINISTRATION. 8VAC20-780 STAFF QUALIFICATIONS AND TRAINING. 8VAC20-780 Physical plant. 8VAC20-780 STAFFING AND SUPERVISION. 8VAC20-780 PROGRAMS. 8VAC20-780 Special care provisions and emergencies. 8VAC20-780 SPECIAL SERVICES. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 22.1 Early Childhood Care and Education

Comments:

An unannounced renewal inspection was conducted on-site on March 16, 2022 and concluded remotely March 21, 2022. The director was available during the inspection. Documents were reviewed remotely. There were 10 children present, ranging in ages from 9 years to 10 years, with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 2 child records, 2 staff records, and 4 board member records, and 1 agent record were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	22.1-289-036-B-4
Description:	Based on a review of board member records, the center did not ensure to obtain an out-of-state central registry check and an out-of-state sex offender registry check before the end of the 30th day for each new board member. Evidence: The record of board member #1, took office July 1, 2021, did not contain documentation of an out-of-state central registry and out-of-state sex offender check.
Plan of Correction:	The out of state sex offender check and criminal background check were performed on July 19, 2021. We acknowledge the central registry was not complete at this time. The FL central registry form was completed and emailed on 3/25/22 and documentation of that is provided with this correction plan. Board Officer files will be reviewed annually.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of records and interview the center did not obtain results of a check of the out-of-state sex offender registry and out-of-state criminal name search by 12/31/20 for each employee hired prior to 7/1/20 and did not request an out-of-state search of the child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years. Evidence: The record of staff #2 (hired 10/17/18) contained documentation of an out-of-state sex offender registry check and an out-of-state criminal name search dated 3/17/22. The record did not contain documentation of the results of an out-of-state central registry check. Staff #2 identified living in another state in the past 5 years on the staff's sworn statement. Administration acknowledged the results were not complete.
Plan of Correction:	As noted, the out of state sex offender registry and out of state criminal checks were done once discovered not completed on 3/17/2022. The out of state central registry check form was completed and mailed with payment on 3/25/22. Documentation of that being sent is provided with this correction plan. In addition, a field has been added to the HR people management system to alert both the employee and manager of an upcoming renewal after five years 60 days before expiration to prompt reperforming background checks.
Standard #:	22.1-289.036-A
Description:	Based on a review of agent records, the center failed to obtain central registry results and a sworn statement every five years for all agents. Evidence: 1. The record of agent #1 (effective 3/19/12) contained documentation of a central registry result dated 3/3/22. The last central registry in agent #1's file is dated 12/13/16. 2. The record of agent #1 contained documentation of a sworn statement dated 12/5/16. 3. The record of board member #4 (took office 6/28/16) contained documentation of a central registry dated 12/15/16 and documentation of a sworn statement dated 10/2/16.
Plan of Correction:	For Agent #1, since he is also an employee of the organization, a field has been added to the HR people management system to alert both the employee and manager of an upcoming renewal after five years 60 days before expiration to prompt re-performing background checks. His sworn statement has been updated as of 3/25/2022 and documentation is provided to VDOE with this correction plan. Board Officer files will be reviewed annually and his background check is in process of being updated and will be provided to VDOE upon completion.
Standard #:	8VAC20-780-550-B
Description:	Based on a review of the emergency preparedness plan the center did not ensure the emergency preparedness plan contained all procedural components. Evidence: The emergency preparedness plan did not contain the following documentation: 1) securing emergency contact information and information on allergies or food intolerances; 2)methods to ensure any health care needs to include medications and care plans; emergency contact information for staff; and supplies are taken to the assembly point or relocation site; 3) includes method of communication with emergency responders; and 4) procedures to reunite children with a parent or authorized person designated by the parent to pick up the child.
Plan of Correction:	The emergency preparedness plan will be updated to reflect these areas. A revised copy of the plan is provided with this correction plan for review and feedback from VDOE.
Standard #:	8VAC20-780-560-F
Description:	Based on a review of the menu and staff statement, the center did not ensure to follow the most recent, age-appropriate nutritional requirements of a recognized authority such as the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). Evidence: Documentation of the center's menu contains four components of the USDA's five component requirement for lunch and dinner. Staff reported four components are served at dinner. Administration confirmed that four components have been served.
Plan of Correction:	The menu format has been updated to more clearly layout each component of the USDA food group components (protein, grain/starch, 2 vegetable/fruit, and dairy). A copy of the updated format is provided to VDOE with this corrective plan for review and feedback.
Standard #:	8VAC20-780-560-J
Description:	Based on staff interview, the center did not ensure tables are sanitized using a spray disinfectant solution before and after each use for feeding. Evidence: Staff reported that tables are sanitized by dipping a rag into a bucket of detergent and wiping the tables. Administration confirmed this is the center's process.
Plan of Correction:	As of March 21, 2022, all sanitation buckets were removed and replaced with industry standard spray bottle disinfectants. A color-coded system is used to designate rags for specific uses (e.g. green rags for wiping tables).